A Medical Glimmer

dump the debt

Dump The Debt, by Friends of the Earth International via Flickr

The largest problem for America right now is not terrorists threatening to kill Americans, like they killed three thousand Americans 10 years ago. (In 2008, 39,000 Americans died in automobile accidents.) No, the biggest problem is economics, a.k.a., debt. And, as post after post and most newspaper articles seem to agree, the unreasonable costs of medical care in this country are at the heart (pun intended) of the problem. We pay double what other countries pay for comparable results.

But short of radically changing to a single-payer government system of medical care, nobody seems to have a viable solution that covers everybody, although there has been some agreement in these blog pages that if we could get consumers to care about costs, i.e., to get some “skin in the game”, Adam Smith’s “invisible hand of the market” might bring down costs. To that end I previously blogged about “concierge care” as one possibility.

Anyone can bandage with bandages. It takes a k...

Image via Wikipedia

Now in a USA Today article (8/29/2011, p. 10B) comes perhaps another glimmer of hope in the form of clinics staffed not by doctors but by Nurse Practitioners and Physician’s Assistants. For about $59 or so you can be seen and treated for relatively minor ailments or conditions and be on your way quickly. Now obviously this is not appropriate for chest pains, broken bones, concussions or chronic conditions. But it sounds great for splinters, swimmer’s ear, poison ivy, sprained ankles and immunizations. It really shouldn’t take a doctor for such things – the treatments are straightforward.  (Hmm.  I wonder if these clinics can process tests like pregnancy, PSA’s, blood sugar, cholesterol, triglycerides, and HIV?)  You can read the whole article HERE.

This possibility of cutting costs (and waiting time) made me wonder, though, “Can NP’s and PA’s write prescriptions?”  I went to Wikipedia, that encyclopedic wonder that, being free is worth more than the hundreds of dollars people used to pay for an already out-of-date printed set. What I found surprised me.  It said,

National or local (i.e. state or provincial) legislation governs who can write a prescription. In North America, physicians (either M.D. or D.O.) have the broadest prescriptive authority. Many other healthcare professions also have prescriptive authority related to their area of practice. Veterinarians, dentists, and podiatrists have prescribing power in all 50 states and the District of Columbia. Clinical pharmacists are allowed to prescribe in some states through the use of a drug formulary or collaboration agreements. In all states, optometrists prescribe medications to treat certain eye diseases, and also issue spectacle and contact lens prescriptions for corrective eyewear. All 50 States allow registered certified Nurse practitioners (ARNP’s)prescription power (with some limitations to controlled substances). Several states have passed RxP legislation, allowing clinical psychologists (PhD’s or PsyD’s) who are registered as medical psychologists and have also undergone specialized training in script-writing to prescribe drugs to treat emotional and mental disorders. Physician assistants (PAs) have some prescriptive authority in all 50 states and the District of Columbia. Florida Pharmacists can write prescriptions for a limited set of drugs.

I hail this as good news. Such clinics are not going to solve the problem by themselves, obviously, but I see their sudden emergence as evidence that the hidden hand of the market has sensed the problem and begun to respond. Hope lives, even if it’s only a glimmer.

Advertisements

About Jim Wheeler

U. S. Naval Academy, BS, Engineering, 1959; Naval line officer and submariner, 1959 -1981, Commander, USN; The George Washington U., MSA, Management Eng.; Aerospace Engineer, 1981-1999; Resident Gadfly, 1999 - present. Political affiliation: Independent, tending progressive as the GOP recedes from its Eisenhower roots.
This entry was posted in Health and tagged , , , , , , , , , , , , , . Bookmark the permalink.

18 Responses to A Medical Glimmer

  1. John Erickson says:

    Thinking back upon my history with the ER, I think clinics using NPs and PAs would be a big help. When I was at my worst with my headaches, only a shot of Delauded (something like Demarol) would quiet the pain. I had to tie up an ER doctor and nurse, plus staff, for a 5-second jab in the arm. On the other hand, when there with an acute attack of pancreatitis (which took me straight from the ER to a hospital bed), I was passed over in the ER for people who had metal splinters in the eye, and kids sick with hacking coughs. I understand the concept of triage, but a shot for pain doesn’t need an ER, and neither does little Billy with a bad cough and helicopter parents. The time savings alone would pay for the clinics, much less clearing the ER of “quick-and-easy” cases.
    By the by, both in Ohio and Illinois, if you need prescriptions for your dog, talk to your human doctor. Many “name brand” animal meds are HIDEOUSLY expensive for Fido or Garfield, but you can often get “human” drugs that can be substituted for the vet drug. And if you have a prescription co-pay, it’s an even further savings. Abuse of the system? Yes. But after what “the system” has put me through all my life, I don’t think my $20 savings here and there will collapse our health system! 😉

    Like

    • Jim Wheeler says:

      Very interesting, John. BTW, we have a Yorkshire Terrier (“Winston”) and he takes prescription heartworm pills and the Flea/Tick stuff that goes on the skin and into the bloodstream – about $60 for a 6-month supply I believe. But, I saw a sign at Walmart that made me think it had gone generic. I hope so.

      Thanks.

      Like

  2. ansonburlingame says:

    To both,

    When the going gets tough in many cases today, standards get lowered. What used to be a “B” yesterday becomes an “A”. And hardly anyone flunks anymore in public education . That concerns me. But so does the cost of HC as well so I have at best mixed feelings about decreasing the scope of training required to write a prescription. Frankly, “I’m Not Sure, Are You”. But is an idea worth kicking around.

    Here is an example. A PhD psychologist with 30 years experince cannot write a prescription today in Joplin. But a PA with less academic training and far less experience can prescribe anti-depressants. The “check” on that system is that all of the PA’s prescriptions must be reviewed (after the fact) by a psychiatrist, an MD. But considering the turmoil in medical administration, one can only guess how effective that “check” might be.

    John also raises a great point, the use of ERs for “coughs”. When my kids were young and I was under the military HC system either my wife or I had to go to the ER when kids were running a high fever, coughing their heads off and the situation did not respond to home remedy. There was no other option and we could easily wait for 4 hours in the ER to have a throat culture taken and antibiotic prescribed. My guess is some of those “kids with coughs” mentioned above have no other medical option as well. It is the ER or “nothing” from the medical profession.

    I have never been to an “Express Care” medical facility and have no idea if EMTAL applies for the uninsured in such facilities. But I hear that one can “get in and out” much quicker than in an ER and I suspect at much less cost as well.

    Now consider an “Express Care” facility staffed mainly with PAs or even just nurses, college graduate, registered nurses backed up with only one physician whose job would be limited to strictly supervision of the care rendered therein. Diagnosis and treatment of individual patients would be done by the lower trained staff. Is that what goes on today in EC as opposed the ER?

    The problem there is how much does it cost just for the physician in such facilities? What salary would he/she receive as a bottom line. My guess is he/she would be paid less money than an ER doctor. So why would any physician agree to work for less money? Alturism only goes so far.

    In these discussions over cost reduction in HC I keep going back to my own recent experience with my wife whose 12 hour stay in a hospital cost $30,000 for Medicare and Tricare. That just boggles my mind. And considering her condition at the time (a stroke occuring “on the table”) the standards of care rendered were…… They did not even give her an asprin. All they did was “monitor her condition”.

    Now $3000 per hour for a major invasive “test” requiring great skill and training is one thing and probably warranted. But $2500 an hour for “monitoring her condition” seems……..? No, I do not think her care or lack thereof rose to a level of negligence, not at all. But the charges for her care were……..

    But if I raised hell with Medicare over paying such high charges I would be ignored. Been there, done that once before about 13 years ago. Bureaucrats cannot make individual determinations such as that based on patient complaints. They must only check the “forms” are filled out with the right numbers or codes and then pay the check based on another form or table.

    But such a system is what you get when we move more towards socialized medicine, in my view.

    And typical HC consumer of today, while I was astounded by the bill from the hospital, the bill was in fact paid for by socialized medicine at no cost to me whatsoever. So I did not lose a whole lot of sleep over the matter. At least not nearly as much if I had to pay the bill myself.

    Had I known beforehand what the cost,personally, would have been, I doubt that my wife would have decided to undergo the test in the first place. In hindsight, the test revealed nothing requiring immediate action and she would have not had a stroke as well.

    Now given all of that “information” exactly with whom should I or my wife discuss the above situation to reduce the charged amount and/or make sure such a situation never happened again? Certainly not the prescribing physician (Why did you prescribe THAT test), or the physician performing the test, or the head nurse “monitoring her care” or…….? And if I wrote a letter to the President of the Hospital or the Secretary of HHS, can you imagine the response that I would receive, if a response was even provided???

    And frankly, only because I write and think a lot about the politics of HC and associated cost, I am probably one of the few patients (or “sponsor” of a patient) that would even look at the bill charged to and paid for by Medicare. When I initially reacted (at home) to the bill my wife even said, “don’t you dare make a stink over this”!!! Was she correct? And other than whining in a blog I have not done so.

    Anson

    Anson

    Anson

    Like

    • Jim Wheeler says:

      You seem to assume, Anson, that a physician would be in attendance to supervise an EC, but my sense of the article is that a PA or an NP would be on their own, thus enabling the lower charges. Frankly, that doesn’t trouble me. We would all like to think that when we go to see a physician we receive the full benefit of their long and expensive training, and I’m sure we often do. But on the other hand I think we have both seen that doctors are human and fallible. They get tired and hurried, and they can make mistakes. I have also known medical corpsmen in the Navy who because of their experience were sharper than the doctors at some things – suturing, for example. I guess the point is, the less expensive care can actually be better and faster than the ER, and the practice should engage the invisible hand of the market too – something the ER doesn’t do. (I don’t think EMTALA would apply to the EC because they are run on a cash basis. There are some doctors who have set up practices the same way – minimum paperwork, wham, bam, here’s the ‘script, gimme the cash, we’re done! What a concept!)

      And I can’t help giving the dead horse one more whack to point out the reason for your wife’s unreasonably high charges. You the taxpayer are helping pay for all those “deadbeats” using the ER’s under the present system you like so well. The EMTALA law mandates it.

      Jim

      Like

  3. ansonburlingame says:

    I would also add one other point to the above “story”. We have several physicians in our immediate and local family. I discussed the charges issue with one of them. His response was to not raise any hell over the bill. He said, “If you do that (challenge the physicians or the bill) you will wind up with no one being willing to provide treatment”!!

    Now is that reality or merely “protective action” within the medical community?

    anson

    Like

    • Jim Wheeler says:

      More than half the revenue that flows into hospitals and doctors’ practices comes from Medicare or Medicaid. Half. When you mess with that income, you are messing with their “rice bowl”, as they say in Vietnam. No matter how much whining you hear from the medical community about the inadequacy of such payments, don’t think for a minute it isn’t of supreme importance to them. I hear threats of cutting off Medicare patients because of low payments, and some doctors, including my own have stopped accepting new Medicare patients. But, no way are they going to be turned away en masse. Bottom line: Money rules.

      Like

  4. John Erickson says:

    I’ll pitch in one more observation to stir the pot, then sit back and watch the fun. (Mwah-ha-ha-ha! 😉 )
    I’m not sure about psychiatric drugs, but I do know that both my pain-killers and some other stuff I take are on “schedules”, ratings that limit the amounts and frequency prescribed. In the case of the emergency clinics, those medicines could be listed as restricted so that the NPs and PAs couldn’t prescribe them. Perhaps the same could be done for anti-psychotics and anti-depressants to limit any abuse of those, as well.
    And back to a MUCH earlier point Jim asked about, I believe these clinics could handle blood and cholesterol tests, as there is a “mobile” centre that circles my area, providing cholesterol testing, basic medical testing (BP, pulse, etc.), urine screenings, and so forth. If they can do these tests on wheels, I’m sure a fixed clinic could handle it. (I believe there is a low-cost clinic around here that already does this, but I won’t say for sure, in case my sieve-like memory has betrayed me again.)
    And now, back to Jim in the studio.

    Like

  5. sekanblogger says:

    Single-payer or nothing. Half measures will not suffice.
    Last time I saw a Nurse-practicioner, I had a belly ache. They ran every test they could. Total bill (b4 insurance) was $6,000.
    They are forced to sell testing or be put out of the current system.

    Like

  6. hlgaskins says:

    “Single-payer or nothing. Half measures will not suffice.

    Sekan is right although there is one variation to single-payer which of course is a two tiered system. The differences are minor with the exception that rich folks have the option of purchasing private health care if they’re concerned with universal health care.

    Last time I saw a Nurse-practicioner, I had a belly ache. They ran every test they could. Total bill (b4 insurance) was $6,000.”

    The last time I saw a Nurse-practitioner was the last time I saw one. She couldn’t answer questions that I knew the answers to and that concerned me.

    Nurse practitioners are however adequate for sniffles, band-aids, skinned knees, blood-pressure checks, and some bee stings, but they shouldn’t be writing prescriptions.

    Health insurers are the problem now, and will be until we’ve rid ourselves of them.

    Like

  7. ansonburlingame says:

    To all,

    “Health insurers are the problem now and will be until we are rid of them.”

    My such wisdom. I thought the problem above was doctors and hospitals charged too much money!!!

    And of course with private health insurers being the problem, I am sure HLG will want GOVERNMENT to take over with however many “tiers” might be needed.

    Government, just in the last two years has well demonstrated that it CANNOT:

    1. regulate off shore drilling or clean up the mess left behind.

    2. Deal with a nuclear crisis 5000 miles away (or right here in River City by implication). Remember the story about the breasting feeding mother?

    3. Fight effectively two wars and pay for them as well

    4. regulate or control the housing market and when it blows up in our face do anything constructive about the mess left behind.

    And NOW HLG, with such a government track record you want to put ALL of our HC into one big government basket.

    HOLY COW (or more applicable, S….)!

    Anson

    Like

  8. hlgaskins says:

    “My such wisdom. I thought the problem above was doctors and hospitals charged too much money!!!”

    Health Insurance is based on a simple premise, if the amount of money coming in exceeds the amount going out, then they will profit. Now do your best to believe that health insurers will not risk the lives of those it insures for profit. Where there is money there is greed and where there is greed, there are thieves.

    “Government, just in the last two years has well demonstrated that it CANNOT:

    1. regulate off shore drilling or clean up the mess left behind.”

    So your stating that off shore drilling should be limited since there is no such thing as non risky deep water drilling?

    “1. regulate off shore drilling or clean up the mess left behind.

    2. Deal with a nuclear crisis 5000 miles away (or right here in River City by implication). Remember the story about the breasting feeding mother?

    3. Fight effectively two wars and pay for them as well

    4. regulate or control the housing market and when it blows up in our face do anything constructive about the mess left behind.”

    Anson, that all sounds downright liberal?

    “And NOW HLG, with such a government track record you want to put ALL of our HC into one big government basket.”

    The problem wasn’t with government but with opposing factions of the governing to work on behalf of the people, unless of course they’re living, breathing, corporations.

    Like

  9. ansonburlingame says:

    HLG,

    Think of it this way. If I needed something done by a contractor (build a house maybe) how would I choose the organization to perform the work? Cost would be one. Quality of work, TRACK RECORD of experience in doing the work to high standards in the past.

    In NONE of those categories would I pick government other than national defense.

    So you want a system where money in is much less than money out. That of course is pure government. Except someone must make up the difference to at least make them equal. Without such a requirement government eventually goes bankrupt, just like any business would do.

    So here we are today, making a fast track down the road to bankruptcy and thinking the “rich”, through the force of government can bail us out. I call that NAIVE at least or pure wishful thinking.

    If you want a government system is must at least be self sustaining in terms of money in and money out over the long run.

    Anson

    Like

  10. hlgaskins says:

    “Think of it this way. If I needed something done by a contractor (build a house maybe) how would I choose the organization to perform the work? Cost would be one. Quality of work, TRACK RECORD of experience in doing the work to high standards in the past.”

    Neither would I, but let me ask you a question. Would you choose the private sector to run our military, insure the safety of our food, legislate our laws, run the highway department, urn our police departments, or take care of our nuclear disposal just to name a few? Somethings the private sector does better and somethings are more suited to government. Whenever a moral choice comes into conflict with a business choice, profits always win.

    “So you want a system where money in is much less than money out. That of course is pure government. Except someone must make up the difference to at least make them equal. Without such a requirement government eventually goes bankrupt, just like any business would do.”

    You must be experiencing a loss of oxygen resulting from inadequate blood flow to the brain because I’ve pointed out time again as many as countries that are paying about half what we’re paying for healthcare, with everyone covered, and better medical outcomes. On top of that 13 of the countries currently receiving a AAA rating all have Universal Healthcare plans, and ten of those are considered the safest countries to invest in. Now hyper ventilate and wrap your brain around that.

    Like

  11. ansonburlingame says:

    OK, HLG,

    National defense, which in a sense include police and fire protection, interstate highways, air trafffic control, security of our borders, etc are indeed government responsibilities and authorized in the Constitution, as I read it using thoughtful, not political interpretation of the Commerce Clause.

    But for the other “stuff”, if it is not in the Constitution as written, then stop doing it at least federally or change the Constitution. Again, no penumbras or use of the “forward” or preface to the Constitution.

    And for damn sure if we cannot pay for whatever laws we pass, particularly with questionable Constitutional authority, then don’t pass the laws until we CAN pay for “it” or change the Constitution, as well.

    Anson

    Like

  12. hlgaskins says:

    “National defense, which in a sense include police and fire protection, interstate highways, air trafffic control, security of our borders, etc are indeed government responsibilities and authorized in the Constitution, as I read it using thoughtful, not political interpretation of the Commerce Clause.”

    Baloney! Everyone of those services listed above are different, but they do all have one thing in common. They’re there to insure that we remain a viable and thriving nation.

    “But for the other “stuff”, if it is not in the Constitution as written, then stop doing it at least federally or change the Constitution. Again, no penumbras or use of the “forward” or preface to the Constitution.”

    It wasn’t necessary to include healthcare 224 years ago when one could pay for a doctor with a chicken. Today medical care is beyond the reach of over 45 million Americans, and if taking care of these people are not in the interest of the country, then I don’t know what is.

    “And for damn sure if we cannot pay for whatever laws we pass, particularly with questionable Constitutional authority, then don’t pass the laws until we CAN pay for “it” or change the Constitution, as well.”

    Do you have any idea as to just how ridiculous the above statement is? What it implies is that we’re better off continuing on with what is arguably the most expensive and inefficient healthcare system on earth. After all, we would be crazy to try and reduce our healthcare costs by 8% to 9% of GDP annually, and just imagine the disastrous effect it could have on the well-being of our billionaire healthcare lords. They need our hard earned dollars to continue with their republican bribe money, and pay for their mansions.

    Never mind that these healthcare barons take money out of the system, while giving nothing back for it, since their aim is self enrichment and not the public interest. I’ve got a novel idea! Let’s take their ill gotten gains and use it to fund our current healthcare crisis. Then we could negotiate a better price with drug companies, hospitals, doctors, technology, and at the same time reduce litigation. We can reduce the 62% bankruptcies related to healthcare since 80% of them already have health insurance. Doctors won’t mind a minor drop in income for the sake of convenience and lower costs in other areas. Perhaps that’s why better than 60% of them support universal healthcare.

    Here, ask these people what they think of a single payer system.

    http://www.pnhp.org/

    Like

  13. ansonburlingame says:

    To both,

    Sure there are some physicians calling for Obama style reform of HC, our local Dr. Cox being one of them.

    But as I have said before, our HC costs as a nation are around 19% of GDP today, in the $2,5+ Trillion range. YOU say we can get it down to 8%-9% or around $1.2 Trillion with your approach. Great. Do it AFTER you can convince reasonable people that you can achieve the goal in cost.

    But in the meantime I will recall, vividly the “promise” made by Obama that unemployment would not go above 8% if his stimulus bill was passed. To me real facts and a track record of not delivering that which is promised make me NOT want to hire such a “contractor” for anything affecting me or my families well being.

    I also recall the rhetoric before passing Obamacare how that legislation would REDUCE the cost of HC. Did I misunderstand that claim along with “we won’t know what’s in it until we pass it” by the former Speaker of the House.

    As for you HLG, you keep talking about 45 million Americans, the poorer ones. Well look at what is happening today with the other 255 million Americans. When you propose something that will improve the conditions of ALL Americans and stop your class “rants”, I might listen.

    Anson

    Like

  14. hlgaskins says:

    “Sure there are some physicians calling for Obama style reform of HC, our local Dr. Cox being one of them.”

    Not some doctors Anson, most of them are for a far more comprehensive healthcare system than Obama’s.

    “But as I have said before, our HC costs as a nation are around 19% of GDP today, in the $2,5+ Trillion range.”

    That’s because of the system that your bent on retraining and has nothing to do with healthcare reform.

    “YOU say we can get it down to 8%-9% or around $1.2 Trillion with your approach.”

    I say it because it’s been successfully done by more than 30 other OECD nations. What can they do that we can’t do?

    “Great. Do it AFTER you can convince reasonable people that you can achieve the goal in cost.”

    It’s the reasonable people that are already convinced. The difficult task is convincing unreasonable people such as yourself.

    “also recall the rhetoric before passing Obamacare how that legislation would REDUCE the cost of HC.”
    We really don’t know what Obama care is going to cost until it’s fully implemented but that being said, the bill was watered down before it was passed. The problem with Obama care is that it’s an incomplete solution. It’s like buying an expensive race car and then putting it on the track with a Volkswagen engine.

    “As for you HLG, you keep talking about 45 million Americans, the poorer ones. Well look at what is happening today with the other 255 million Americans. When you propose something that will improve the conditions of ALL Americans and stop your class “rants”, I might listen.”

    If we’re looking at rants, I would say that better describes your attempts at debate since they’re not based on any factual information. My posts on the other hand have been solidly backed by data and statistics. You are so full of FOX and Limbaugh poison that you’re incapable of listening to any view that discredits theirs and yours.

    Like

Leave a Reply

Please log in using one of these methods to post your comment:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s